Leslie S. Welborne, M.D.CENTENNIAL OB/GYN, P.A.Melissa Bailey, M.D.
Alisa Ward, M.D.5757 Warren Parkway, Suite 210Ruth Whiddon, W.H.N.P.
Frisco, TX 75034
PH: 972-731-6565 FX: 972-731-6570
Name ______DOB ______Marital Status _____ Date ______
Reason for Visit
______
Allergies to Medications
If yes, please name medicine and describe type of reaction ______
Medications and Supplements
Please give name and dosage______
Pregnancy History
Total Pregnancies___ Full Term___ Pre-term___ Miscarriage___ Abortion___ Ectopic__
Date Length of Pregnancy Type of Delivery Sex Weight Living Complications
______
______
______
______
Menstrual History
At what age did you start having menstrual periods? ______
Number of days between first day of one and first day of next period? ______
Length of period? ______Regular or Irregular ______
Would you call your periods ( ) light ( ) medium ( ) heavy ( ) clots
When was the first day of your last menstrual period? ______Do you have cramps?_____
Was it a normal period? ______If not, when was the last normal one? ______
Would you like information on a simple, safe procedure performed in our office that can significantly reduce or eliminate your monthly periods/cramps? __ Y __ N
Contraception
What is your current form of birth control?
Abstinence Birth Control pill Hysterectomy IUD Menopause Tubal ligation Vasectomy Nuvaring Patch Depoprovera Rhythm Condoms
How long have you been using your current form of birth control? (please check one)
__ 2 yrs or less__ 3-5 yrs__ 6-10 yrs__ over 10 yrs
When are you planning to have another child? (please check one)
__ within 1-2 yrs__ within 5-10 yrs __ my family is complete
Would you like information on a gentle, hormone-free permanent birth control procedure performed in the comfort of our office? __ Yes __ No
If menopausal, at what age did your periods stop? ______
Date of last pap smear? ______Normal/Abnormal? Have you had an abnormal pap smear? _____
If yes, please give dates, type (ASCUS, HPV, CIN I, etc.) and treatments (Colposcopy, Cryo, Cone Biopsy, LEEP) ______
Date of last mammogram? _____ Normal/Abnormal? Have you had an abnormal mammogram? ____
If yes, please give dates and explain: ______
Date of last Bone densitometry? ______Normal / Osteopenia / Osteoporosis
Past Medical History
Please check if you currently have or have had a history of any of the following:
Leslie S. Welborne, M.D.CENTENNIAL OB/GYN, P.A.Melissa Bailey, M.D.
Alisa Ward, M.D.5757 Warren Parkway, Suite 210Ruth Whiddon, W.H.N.P.
Frisco, TX 75034
PH: 972-731-6565 FX: 972-731-6570
YES NO
( ) ( ) Reflux/Heartburn
( ) ( ) Spastic Colon/Irritable Bowel
( ) ( ) Hepatitis
( ) ( ) Ulcers
( ) ( ) Hypertension
( ) ( ) Heart Disease
( ) ( ) Angina
( ) ( ) Heart Murmur
( ) ( ) Hypercholesterolemia
( ) ( ) Blood Clotting Problems/DVT
( ) ( ) Asthma
( ) ( ) Sleep apnea
( ) ( ) Tuberculosis
( ) ( ) Pneumonia
( ) ( ) Emphysema
( ) ( ) Kidney/Bladder Infections
( ) ( ) Kidney Stones
YES NO
( ) ( ) Fibromyalgia
( ) ( ) Arthritis-Rheumatoid/Osteo
( ) ( ) Diabetes
( ) ( ) Thyroid Problems
( ) ( ) Osteoporosis
( ) ( ) Nervous Disorder/Depression
( ) ( ) Rheumatic Fever
( ) ( ) Migraines
( ) ( ) Dementia
( ) ( ) Stroke/TIA
( ) ( ) Epilepsy
( ) ( ) Anemia
( ) ( ) Sickle Cell Disease/Trait
( ) ( ) Allergies
( ) ( ) Eczema
( ) ( ) Psoriasis
( ) ( ) Cancer______
Leslie S. Welborne, M.D.CENTENNIAL OB/GYN, P.A.Melissa Bailey, M.D.
Alisa Ward, M.D.5757 Warren Parkway, Suite 210Ruth Whiddon, W.H.N.P.
Frisco, TX 75034
PH: 972-731-6565 FX: 972-731-6570
( ) ( ) Hospitalizations - If yes, please explain: ______
______
Past Surgical History
Dates: Procedure:
______
______
______
______
______
Immunizations (please list dates)
Tetanus: ______HPV: ______Flu: ______
Who is your Primary Care Physician? ______
Family History
YES NO YES NO
( ) ( ) Breast Cancer ( ) ( ) Diabetes
( ) ( ) Ovarian Cancer ( ) ( ) Thyroid Disorder
( ) ( ) Uterine Cancer ( ) ( ) Osteoporosis
( ) ( ) Colon Cancer ( ) ( ) Epilepsy/Seizures
( ) ( ) Heart Disease ( ) ( ) Stroke
( ) ( ) Hypercholesterolemia( ) ( ) Depression/Bipolar/Schizophrenia
( ) ( ) Hypertension ( ) ( ) Birth Defects
( ) ( ) DVT/Pulmonary Embolus ( ) ( ) Other
If yes, please explain ______
Social History
Employer/Occupation ______Marital Status______Exercise Type/Frequency______Education Level______
Smoking___cigs/day Alcohol___drinks/wk Caffeine ___servings daily Illicit Drugs ______Have you ever had a sexually transmitted disease? ______Type/dates______
Review of Symptoms: (Circle current symptoms)
GENERAL - Fatigue Fever Weight gain Weight loss
CARDIOVASCULAR – Palpitations Chest pain
PULMONARY - Cough Shortness of breath
GASTROINTESTINAL - Bloating Constipation Diarrhea Hemorrhoids Bloody stools Nausea
URINARY - Pain with urination Blood in urine Frequency UTI’s Incontinence
GENITAL - Irregular periods Painful intercourse History of sexual abuse Vaginal discharge Vaginal itching
MUSCULOSKELETAL - Back pain Joint pain
BREAST –Perform self breast exams-Regularly/Irregularly/Never Masses Tenderness Nipple discharge
SKIN - Rash Warts
NEUROLOGIC - Dizziness Headaches
BLOOD/LYMPHATIC - Easy bruising Bleeding easily History of blood transfusion Enlarged lymph nodes
ENDOCRINE – Hair loss Temperature intolerance Excessive hair growth
ALLERGIES – Seasonal allergies
PSYCHIATRIC - Anxiety Depression PMS Insomnia